In a joint investigation with the Washington Post, CBS 60 Minutes correspondent Bill Whitaker recently explored the opioid crisis and its causes, concluding that a 2016 law contributed to the epidemic by diminishing the power of the nation’s biggest drug busters, the Drug Enforcement Agency (DEA).
The segment cast characters in a rather simplistic story about good guys (DEA officers) versus bad guys (the pharmaceutical industry and politicians who were in their pocket). Given present cynicism toward “the political swamp,” it would be easy to believe.
But this over-simplified narrative misses some of the roots of the opioid problem, which took hold long before 2016. Between 1999 and 2015, opioid-related deaths quadrupled. Only in recent years have there been efforts to stem the epidemic, and on a positive note, opioid prescriptions have decreasedabout 18 percent between 2010 and 2015. Much of the challenge now lies in combatting illicit opioids, including heroin and synthetically-produced fentanyl.
Certainly our public policies played a role in fostering the initial wave of legal opioid prescriptions, but perhaps surprisingly, these were nice-sounding policies pushed with very good intentions, not evil efforts to gut enforcement agencies or enrich big business.
For example, the Centers for Medicare and Medicaid Services use, among other inputs, customer satisfaction surveys to determine payments to providers. Most people may agree that customer satisfaction is important and worthy of measuring and maximizing, but for years – until a very recent change in January of this year – these surveys included questions about pain management.
If patients weren’t satisfied with how their doctors treated their pain, doctors were dinged. This represents one of the challenges of medicine: doing what pleases patients in the short run isn’t always what’s best for their long-run health. Sadly, these survey questions encouraged a bad culture in hospitals of over-prescribing opioids for pain management.
Here’s another example: The Joint Commission (JC, formerly known as the Joint Commission on the Accreditation of Healthcare Organizations) encouraged very aggressive pain assessment guidelines. This may not sound like an influential factor, but it’s important to understand the JC’s role: It operates under a unique statutory mandate to accredit hospitals to work with Medicare and Medicaid, giving it enormous power to dictate hospital policy. Medicare and Medicaid are the biggest payers in our health system. Hospitals badly need this accreditation.
Last year, dozens of health providers and groups sent a letter to the JC, saying that its standards “encourage unnecessary, unhelpful, and unsafe pain treatments that interfere with primary disease management.” The letter asked that JC change its standards to allow individual clinicians to use their judgment for pain assessment rather than mandating routine pain assessment.
Advocacy organizations played a role in all of this as well: The American Pain Society began a campaign as early as the 1990’s to elevate pain to be the “fifth vital sign.” This was obviously an effort to ensure that providers took their patients’ pain seriously, but pain, unlike other vital signs like temperature and heart rate, cannot be measured objectively. Asking patients to report their own pain sadly opens the door to addicts who want to abuse the system.
It would be comforting if we could reduce the opioid crisis to a simple narrative about bad actors and their innocent victims. But reality is more complex than that. Even policies crafted with the best of intentions in wanting to help and comfort patients can end up causing harm. And in this case, our government’s central planning and over-standardization contributed to the opioid crisis.
This should be warning for the future: Instead of heavy-handed guidelines and rules, the best patient protection is to empower individual physicians to use their own clinical judgment, without any pressure to prescribe pain pills or meet certain government-imposed metrics. Policies have to be judged by their outcomes, not just their intentions.